Belal AA, Santos Jr AH, Koratala A, Kazory A. Expanding the boundaries of kidney replacement therapy in patients with liver failure. World J Crit Care Med 2025; 14(3): 105235 [DOI: 10.5492/wjccm.v14.i3.105235]
Corresponding Author of This Article
Amer A Belal, MD, Assistant Professor, Division of Nephrology, Hypertension and Renal Transplantation, University of Florida, 1600 SW Archer Road, Gainesville, FL 32610, United States. amer.belal@medicine.ufl.edu
Research Domain of This Article
Critical Care Medicine
Article-Type of This Article
Minireviews
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
World J Crit Care Med. Sep 9, 2025; 14(3): 105235 Published online Sep 9, 2025. doi: 10.5492/wjccm.v14.i3.105235
Expanding the boundaries of kidney replacement therapy in patients with liver failure
Amer A Belal, Alfonso H Santos Jr, Abhilash Koratala, Amir Kazory
Amer A Belal, Alfonso H Santos Jr, Amir Kazory, Division of Nephrology, Hypertension and Renal Transplantation, University of Florida, Gainesville, FL 32610, United States
Abhilash Koratala, Division of Nephrology, Medical College of Wisconsin, Milwaukee, WI 53226, United States
Author contributions: Belal AA contributed to the writing of the original draft, literature review, critical revision and editing, and approval of the final version of the manuscript; Santos Jr AH contributed to the revision and approval of the final version of the manuscript; Koratala A contributed to the revision and approval of the final version of the manuscript; Kazory A contributed to the conception and design of the work, critical revision, editing, and approval of the final version of the manuscript.
Conflict-of-interest statement: All the authors declare that they have no conflict of interest.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Amer A Belal, MD, Assistant Professor, Division of Nephrology, Hypertension and Renal Transplantation, University of Florida, 1600 SW Archer Road, Gainesville, FL 32610, United States. amer.belal@medicine.ufl.edu
Received: January 16, 2025 Revised: March 18, 2025 Accepted: March 28, 2025 Published online: September 9, 2025 Processing time: 184 Days and 15.5 Hours
Abstract
Acute kidney injury (AKI) is common in patients with liver failure, and for a significant subset it is severe enough to require kidney replacement therapy (KRT). Patients with liver failure have distinct clinical characteristics (e.g., cardio-circulatory dysfunction and a tendency to bleed) that mandate customization of their overall care including KRT. Herein, we provide an overview of AKI in liver failure, discuss the basic pathophysiology of hepatorenal syndrome, including the often-underemphasized role of the heart in its clinical manifestations, and the current therapies afforded to these patients. We also discuss the general aspects of KRT and how they apply to patients with liver failure (e.g., preference for continuous renal replacement therapy and the need for regional, instead of systemic, anticoagulation). Moreover, we discuss hyperammonemia, an emerging non-renal indication of KRT in this patient population, and provide recommendations on how this therapy may be applied in this setting.
Core Tip: Acute kidney injury (AKI) is common in patients with liver failure, and a significant subset requires kidney replacement therapy (KRT). These patients have distinct clinical characteristics and needs that mandate customization of their overall care, including KRT. This general overview is meant for critical care providers to familiarize themselves with the nuances of KRT in patients with concomitant liver failure and AKI.
